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The Effectiveness of 12 Step Based Recovery

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Recent research offers compelling support for the effectiveness of Twelve Step-based treatment

--by Doug Toft

When academics and members of Alcoholics Anonymous meet, they tend to confirm how much they differ.

People in AA see themselves as part of a fellowship, bonded by the shared disease of alcoholism and relying on a spirituality that defies measurement. In contrast, university-based researchers want numbers--objective outcome measurements for treatment based on the Twelve Steps and results that can be replicated. AA testimonials are interesting, researchers say, but we need more reliable evidence that joining a Twelve Step fellowship changes people over the long term.

Given their divergent perspectives, we might expect these two groups to keep a polite distance or even harbor some mutual suspicion. But today that expectation cannot hold. A growing number of researchers not only profess respect for AA, they see the Twelve Steps as essential to addiction treatment.

Researchers call for reconciliation with AA

This reconciliation of the scientific community with AA has been hard-won. For decades, only a few studies documented the effectiveness of Twelve Step-based treatment.

That's understandable. To preserve anonymity, AA keeps few statistics other than numbers of groups and members. For the 65 years of its existence, AA has grown by anecdotal accounts of recovery among its members--not by the results of research published in peer-reviewed medical journals.

When approached by outside observers, some members of AA even express caution. Charlie Bishop, coauthor of To Be Continued: The Alcoholics Anonymous World Bibliography 1935-1994,1 argues that scholars who try to categorize AA as a form of therapy do it a disservice. According to Bishop, AA can be properly taken only on its own terms as a spiritual fellowship, not merely a treatment strategy or way to modify behavior that can be couched in modern psychology.

"Research on AA should be approached gingerly," Bishop adds. "The underlying difficulties of applying the scientific method to spirituality should give every scholar pause. If a scientist were to ask an AA old-timer how AA works, the answer Just fine! could be expected."

However, that wasn't always the answer to expect from professionals in psychology and medicine. "It's been very fashionable among psychologists to badmouth AA--without, by the way, having ever attended an AA meeting," says Thomas McClellan, PhD, director of the Treatment Research Institute at the University of Pennsylvania, Philadelphia. "It gets under the skin of psychologists--the idea that you're powerless, the idea that there are catch phrases and simple things done by lay people that will be powerful tools." Today, professionals with such attitudes owe AA an apology, adds McClellan.

Robert Fiorentine, PhD, director of Research Training at the UCLA Drug Abuse Research Center, echoes this call for conciliation. "There has been hostility among researchers partly because of the spiritual emphasis of AA," says Fiorentine. "There is still hostility, but because of the recent evidence indicating the effectiveness of the Twelve Steps in assisting in recovery, this hostility among researchers seems to be diminishing."

Largely responsible for this change in attitude is a spate of studies about AA and the Twelve Steps--about 150 of them since 1980. But the most significant studies documenting Twelve Step efficacy have come in the last five years.

Project MATCH supports Twelve Step-based treatment

One of the largest and most widely quoted studies to support the "AA works" philosophy is Project MATCH, published in 1998.2 This federal effort was supported by the National Institute on Alcohol Abuse and Alcoholism.

The study's title captures its aim: finding ways to match people with the kind of addiction treatment best suited to them. Doing this means looking for "client attributes"--personal characteristics--that reliably predict how well people will do when assigned to specific kinds of treatment. Examples of those attributes are anger and readiness to change. Project MATCH examined 21 such attributes.

In addition, Project MATCH compared three kinds of treatment, each delivered via individual outpatient therapy:

** Twelve Step Facilitation Therapy, grounded in AA's concepts of alcoholism as a disease of the mind, body, and spirit and lifelong abstinence as the only sane response. This form of treatment guides clients through AA's first five steps. It also actively encourages people to attend AA meetings, keep a journal of their experiences at meetings, read AA literature, and practice AA principles "in all our affairs."

** Cognitive Behavioral Therapy, which helps people master skills that are essential to staying sober, in particular, relapse prevention. This means learning to identify cravings for alcohol and respond to those cravings in ways other than drinking. Some of those skills include challenging the thoughts used to rationalize drinking and avoiding the "people, places, and things" linked to alcohol or other drug use.

** Motivational Enhancement Therapy, designed to help clients discover and act on their personal reasons for staying sober. Motivational enhancement therapists help clients move through six specific stages of change: pre-contemplation (not considering a behavior change), contemplation (considering a change), preparation, action, maintaining the change, and coping with relapse.

Researchers could hardly have chosen three approaches that differ so much.

Cognitive Behavioral Therapy offers technique after technique for helping people change their thinking (cognition) and action (behavior). It's true that the Twelve Steps also guide people to release "stinking thinking" and change behavior. However, AA members put these attempts to change in the context of surrender to a higher power. Cognitive Behavioral Therapists, ground in social learning theory, make no such assumptions about the need for "conscious contact."

Motivational Enhancement Therapy also differs from the Twelve Steps. In this form of therapy, counselors make no attempt to guide clients through a step-based program of recovery. Instead, counselors offer non-judgmental feedback on clients' behavior, emphasize personal responsibility for change, and offer a menu of options for new behaviors. Sometimes Motivational Enhancement Therapists offer outright advice.

Among these three approaches, Twelve Step Facilitation is the only one that specifically encourages people to reach out to other recovering alcoholics. Helping clients to actively work the Twelve Steps is the primary goal, as opposed to learning skills that the therapist teaches or responding to therapist feedback.

For Project MATCH, 806 clients in five outpatient treatment centers were randomly assigned to these three treatments. Researchers also interviewed and assessed clients to rate them on relevant attributes.

The overall results were reported in 1998: Almost 30 percent of these clients were abstinent three years after treatment. And even those who drank during those three years abstained, on average, two-thirds of the time. Of the 21 client attributes, two were the most powerful predictors of long-term drinking outcome: readiness-to-change and self-efficacy (clients' confidence in their ability to abstain).

Project MATCH found few differences in outcomes among the three treatments. This means that Twelve Step Facilitation held its own, working as well as Cognitive Behavioral Therapy and Motivational Enhancement Therapy. In fact, Twelve Step Facilitation offered a statistically significant advantage when total abstinence was the desired outcome.

Steps help clients who have social support for drinking

Another relevant study comes from Richard Longabaugh, EdD, associate director of the Center for Alcohol and Addiction Studies at Brown University, Providence, Rhode Island, and his colleagues.3 This study, part of Project MATCH, clearly demonstrates the advantage of Twelve Step Facilitation for clients with a particular attribute: social support for drinking.

To rate clients on this attribute, researchers looked for specific information, such as the:

** Number of people in the client's social network.

** Amount of contact that the client had with key people in this network.

** Number of heavy drinkers in the network.

** Number of people who abstained from drinking and the number of recovering alcoholics in the network.

In short, clients with high support for drinking had close friends and family members who drank at higher levels and offered lower levels of support for abstinence.

Longabaugh and his coauthors predicted that Twelve Step Facilitation Therapy would lead to better treatment outcomes for these clients. To test this hypothesis, researchers measured the number of days that clients abstained from alcohol during a three-month period--37 to 39 months after treatment. Researchers also measured client involvement in AA during and after treatment.

Results confirmed the prediction: Clients with high network support for drinking who took part in Twelve Step Facilitation had 83 percent abstinent days; those who received Motivational Enhancement Therapy had 66 percent.

What's more, even the clients who received Motivational Enhancement Therapy had more abstinent days if they attended AA after treatment. For clients with low network support for drinking, there was no significant difference between Twelve Step Facilitation and Motivational Enhancement Therapy.

Researchers drew two primary conclusions from this study: Twelve Step Facilitation "may be the treatment of choice" for alcoholics with networks that support drinking. And, alcoholics with such networks should consider joining AA--regardless of the type of treatment they receive.

Our study has clear clinical significance, says Longabaugh. It tells the clinician that once we know the client's support for drinking, we know how important the AA component can be to his or her recovery.

For his work on this study, Longabaugh received the Dan Anderson Research Award for 1999 from Hazelden. This award recognizes researchers who advance scientific knowledge in the field of addiction recovery.

Steps and treatment offer 'additive effect'

More support for the Twelve Steps as treatment tools comes from the work of Fiorentine. For one study, he and colleague Maureen P. Hillhouse, PhD, followed 356 clients entering outpatient treatment in Los Angeles.4 The researchers interviewed and assessed each client twice--within one week of entering treatment and again about eight months later.

Fiorentine was especially interested in answering these questions:

1. Do people join Twelve Step groups (such as AA and Narcotics Anonymous) as an alternative to treatment?

2. Why do people who are currently active in a Twelve Step group choose to enter treatment?

3. When people are involved in a Twelve Step group before entering treatment, are they more likely to complete treatment?

4. Are longer stays in treatment associated with higher levels of involvement in Twelve Step groups?

5. When people take part in treatment and Twelve Step groups, do they experience an "additive effect"--higher rates of abstinence due to both kinds of participation?

The data provided answers to each question:

** Two-thirds of the outpatient clients were attending a Twelve Step group when they entered treatment.

** Most clients entered treatment to support a "global lifestyle change"--not to simply stay off drugs or comply with a court order.

** Clients who attended Twelve Step meetings at least once per week before treatment stayed in treatment longer--an average of four weeks more--and were also more likely to complete treatment.

** The longer clients stayed in treatment, the more likely they were to contact a sponsor at least once per week.

** Clients who stayed in treatment longer, completed treatment, and attended Twelve Step groups weekly had significantly higher rates of abstinence than those who did not meet these three criteria.

Fiorentine concluded that people used Twelve Step groups and outpatient treatment as "integrated recovery activities," not mutually exclusive options. When clients combine treatment and Twelve Step groups, they experience a powerful advantage over using treatment or groups alone. In summary, treatment and Twelve Step groups are best viewed as a "both-and" proposition, not "either-or."

Treatment tends to be of a limited duration, whereas Twelve Step participation recommends lifelong, regular participation and a sponsorship relationship. Fiorentine speculates that "this regular, continuous, and personal affiliation may be one reason why Twelve Step membership is more effective than treatment in promoting long-term recovery." Another reason is that Twelve Step philosophy accurately depicts the nature of addiction, particularly the notion of powerlessness over alcohol and other drugs, adds Fiorentine.

In other research, Fiorentine determined that those who accept the fact that they are powerless over alcohol and other drugs are significantly more likely to maintain long-term abstinence.5

Minnesota Model produces consistent results

Closer to home is a study published by Randy Stinchfield, PhD, associate director of the Center for Adolescent Substance Abuse at the University of Minnesota Medical School, Minneapolis, and Patricia Owen, PhD, director of the Butler Center for Research at Hazelden.6 This study focused on outcomes of the Minnesota Model treatment as delivered at Hazelden in Center City, Minn.

Stinchfield and Owen collected data on 1,083 men and women at four points: when they entered treatment at Hazelden, and at one month, six months, and 12 months after treatment. At the 12-month point, 53 percent of these people said that they'd abstained from alcohol and other drugs during the year after treatment. Another 35 percent said that they'd reduced their chemical use. Between 70 and 90 percent of these clients also reported improved quality of life in areas such as family relationships and job performance.

These results, consistent with other studies of Minnesota Model treatment, compare favorably with outcomes reported for other private treatment programs.

Keep in mind that the Minnesota Model, with a Twelve Step foundation, fuses many elements: a residential setting, group therapy, individual counseling, lectures, discussions, assignments, attendance at Twelve Step meetings, and more. And as part of the model, clients receive services from a team of counselors, nurses, physicians, psychologists, recreational therapists, and spiritual care specialists. Treatment is individualized, and aspects of Cognitive Behavioral and Motivational Enhancement Therapy are woven in.

But what unifies these disparate elements is Twelve Step philosophy: lifelong abstinence is the goal of recovery, and frequent attendance at Twelve Step meetings is the primary way to maintain abstinence over the long term. Stinchfield and Owen put it this way: "The primary agent of change is group affiliation and practicing behaviors consistent with the Twelve Step program of AA."

Researchers offer kudos, caveats

The studies summarized above offer a sample of the latest round of Twelve Step research. There are more. For instance, the Chemical Abuse Treatment Outcome Registry includes studies showing a correlation between high abstinence rates and AA participation. According to Owen, many studies of Twelve Step-based treatment published since 1995 have used more sophisticated designs and statistical analyses than earlier studies. Among members of the research community, that translates into more credibility for the Twelve Steps.

"It used to be that studies just offered a straight correlation between AA attendance and abstinence," Owen says. "Now studies are looking at all the other variables that are involved to see how important AA involvement is." Among those variables are client characteristics, types of treatment, and length of treatment.

While recent studies point to the power of the Twelve Steps and AA fellowship, they do come with some caveats.

One is that treatments such as Twelve Step Facilitation are technically not the same as AA. In Project MATCH and related studies, this treatment is based on individual counseling sessions with an ultimate purpose of guiding people to join AA. But in itself, AA is not a counseling or treatment program.

Then there are the inherent difficulties of treatment research--problems that dog anyone who attempts the task. In their study of treatment outcomes at Hazelden, Stinchfield and Owen offer these examples:

** After they leave treatment, people can be hard to find. They move, change phone numbers, or just don't respond to requests for follow-up interviews. It's hard to know whether these people are staying sober or not.

** Though many would like to say that addiction treatment leads clients to a life of sobriety, researchers cannot technically make this inference. In order to conclusively demonstrate that treatment itself changes people, researchers would have to randomly assign clients into groups that receive treatment and those that dont; then researchers could compare abstinence rates across groups. However, this procedure involves withholding treatment from some people--an obvious ethical problem.

** Many studies depend on self-reports. That is, the results depend on recovering people to tell the truth about whether they're staying clean and sober.

Researchers are finding creative ways to overcome these difficulties. For example, self-reports can be verified in several ways. One is to look for consistent answers to questionnaire items: If a person claims to be abstinent but still reports problems associated with drinking, this contradiction raises a red flag. Researchers can also interview family members and friends of the recovering person to double check the accuracy of that person's responses.

AA endures

None of the caveats have to be a problem for people who seek sanity, support and sobriety in AA. People who wish to stop drinking or other drug use can continue to enter the fellowship of recovering people at any time. Based on the latest research, these people are making a smart decision. And even when research results are pending, AA's doors are always open.

AA's spirit of tolerance, embodied in the slogan Live and Let Live, offers another way to reconcile research with "real-world" practice of the Twelve Steps. "We must remember that one of AA's successes is it's stand that AA is not the only answer," says Bill Pittman, director of historical information for Hazelden. "AA says it's a suggested program. I think that's important and fits with any research findings." McClellan agrees, even though he concedes that many people who attend AA during treatment do not end up attending regularly. "AA isn't for everybody," he points out. "But what needs to be said--and it's time for psychologists and other professional people to say it--for those who attend, it works damn well."

References

1. Bishop, C. & Pittman, B. (1994).To Be Continued . . . The Alcoholics Anonymous World Bibliography 1935-1994. Wheeling, West Virginia: The Bishop of Books.

2. Project MATCH Research Group (1998). Matching alcoholism treatment to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22, 6, 1300-1311.

3. Longabaugh, R., Wirtz, P.W., Zweben, A, & Stout, R.L. (1998). Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction, 93, 9, 1313-1333.

4. Fiorentine, R. & Hillhouse, M.P. (2000). Drug treatment and 12-step program participation: The additive effects of integrated recovery activities. Journal of Substance Abuse Treatment, 18, 65-74.

5. Fiorentine, R. & Hillhouse, M.P. (2000). Exploring the additive effects of drug treatment and Twelve-Step involvement: Does Twelve-Step ideology matter? Substance Use and Misuse, 35, 367-397.

6. Stinchfield, R. & Owen, P. (1998). Hazelden's model of treatment and its outcome. Addictive Behaviors, 23, 5, 669-683.









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